Modifiedblue cross blue shield - kansasPolicy N/A

Medical Pharmacy Implementation Prior Authorization Program (BCBSKS)

Notifies providers that Blue Cross and Blue Shield of Kansas is transitioning management of certain medical-benefit specialty drugs to Prime Therapeutics' Medical Pharmacy Solutions (MPS) team, effective August 15, 2025, and describes prior authorization (PA) submission workflows, impacted places of service, in-scope HCPCS/J-codes and provider responsibilities.

Policy Summary

Payerblue cross blue shield - kansas

PolicyMedical Pharmacy Implementation Prior Authorization Program (BCBSKS)

Policy CodePolicy N/A

Change TypeVendor transition; PA workflow change

Effective DateAug 15, 2025

Next Review Date

Key ActionObtain prior authorization from Prime Therapeutics Medical Pharmacy Solutions via GatewayPA.com (routine) or 800-424-1713 (urgent/retro) for services on/after 2025-08-15; providers may contact Prime beginning 2025-08-07.

POLICY UPDATE CHANGES

Responsibility for prior authorization reviews for the listed medical-benefit specialty drugs is transitioned to Prime Therapeutics Medical Pharmacy Solutions, effective 2025-08-15.

PA submission workflow changed for providers previously using Prime MDR or Prime Therapeutics Pharmacy Benefit Team via CoverMyMeds/fax.

ManyIn-scope drug HCPCS/J-codes listed

2025-08-15Program effective date

Commercial/ExchangeImpacted member plans

What is changing

Blue Cross and Blue Shield of Kansas (BCBSKS) is transitioning responsibility for prior authorization (PA) reviews of many specialty, practitioner-administered medical-benefit drugs to Prime Therapeutics' Medical Pharmacy Solutions (Prime). The program applies to the practitioner-administered drugs listed in the bulletin and requires PA when administered in the listed places of service for impacted members.

The change applies to Commercial/Exchange member plans and is effective for dates of service on or after 2025-08-15. Providers may begin contacting Prime on 2025-08-07 to obtain prior authorizations for treatments with dates of service on or after 2025-08-15.

Beginning with the effective date, providers must submit PA requests for in-scope medical-benefit drugs to Prime's Medical Pharmacy Solutions team (routine requests via GatewayPA.com; urgent/retroactive requests by phone at 800-424-1713). Providers who previously used the Prime Therapeutics Pharmacy Benefit Team via CoverMyMeds or fax will need to change their PA submission workflow to Prime's MPS processes.

Key facts

Program vendorPrime Therapeutics Medical Pharmacy Solutions (MPS)

PA effective date2025-08-15

Provider contact start2025-08-07

Impacted plansCommercial/Exchange

Places of servicePractitioner-administered POS (see provider actions for requirements)

In-scope HCPCS / J-codes requiring prior authorization

In-scope HCPCS / J-codes (requires PA under program)HCPCS|CPT|mixedCovered

Q2055	Abecma / bendamustine (Baxter) / Elaprase (various brand associations listed)
J9264	Abraxane / Bendeka / Elelyso / Glassia / associated J-codes noted
J3262	Actemra IV / BeneFIX / Elfabrio / Granix / associated J-codes noted
J0801	Acthar_HP / Benlysta IV / Eloctate / Haegarda / associated J-codes noted
J0599	Miscellaneous drug code referenced
J0791	Adakveo / Beovu / Elrexfio / Halaven / associated J-codes noted
J9042	Adcetris / Berinert / Elzonris / Hemlibra / associated J-codes noted
J9029	Adstiladrin / Bkemv / Empaveli / Hemofil M / associated J-codes noted
J7192	Advate / Blincyto / Enhertu / Herceptin / associated J-codes noted
J7207	Adynovate / Breyanzi / Enjaymo / Herceptin Hylecta / associated J-codes noted

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Prior authorization requirement (criteria)

Prior Authorization Requirement for In-Scope Medical-Benefit Drugs

Prior authorization is required by Prime when the drugs are administered by practitioners in the listed places of service and for listed member plans for dates of service on or after August 15, 2025.

Prior Authorization Requirement

Drug in scope: Drug is listed among the in-scope HCPCS/J-codes enumerated in this bulletin (see code_groups).
Place of service is one of the practitioner-administered POS requiring PA as referenced in the bulletin.
Specific POS codes are referenced in the bulletin's 'Places of Service' section.
Impacted member plan: Member is enrolled in an impacted plan (Commercial/Exchange Members).

Actions required of providers

Prior Authorization

New prior authorization vendor and effective date

Beginning August 15, 2025, Prime Therapeutics Medical Pharmacy Solutions will perform prior authorization reviews for the listed medical-benefit drugs; providers must obtain PA from Prime for services on/after this date. Providers may begin contacting Prime on August 7, 2025 for treatments starting on or after August 15, 2025.

Contact Prime beginning 2025-08-07 for treatments on/after 2025-08-15
Effective date: 2025-08-15

Prior Authorization

How to submit PA requests

Providers must submit PA requests for in-scope medical-benefit drugs to Prime via GatewayPA.com for routine requests. Urgent, expedited, or retroactive requests must be phoned to Prime at 800-424-1713. Providers previously using CoverMyMeds and/or fax to request medical-benefit drug reviews must change workflows and begin submitting reviews to Prime's Medical Pharmacy Solutions team.

FAQs & contact instructions

Q: When can providers begin contacting Prime for PA?

A: Providers may begin contacting Prime on August 7, 2025 for treatments with dates of service on or after August 15, 2025.

Q: How are urgent or retrospective PA requests handled?

A: Urgent and retroactive requests must be phoned to Prime Operations at 800-424-1713; Prime has staff available 24/7 for urgent requests by phone.

Quick contacts

PortalGatewayPA.com

Phone for urgent/retro requests800-424-1713

VendorPrime Therapeutics Medical Pharmacy Solutions (MPS)

Definitions

Prime: Prime Therapeutics — the Medical Pharmacy Solutions (MPS) team at Prime will administer the prior authorization program and perform reviews for the in-scope medical-benefit specialty drugs.

GatewayPA.com: GatewayPA.com — Prime Therapeutics' online portal for submitting routine prior authorization requests (urgent/retroactive requests must be phoned to Prime).

Document changes

ChangeLatest

Responsibility for prior authorization reviews for the listed medical-benefit specialty drugs is transitioned to Prime Therapeutics Medical Pharmacy Solutions, effective 2025-08-15.

Change

PA submission workflow changed for providers previously using Prime MDR or Prime Therapeutics Pharmacy Benefit Team via CoverMyMeds/fax.

Policy Summary

Payerblue cross blue shield - kansas

PolicyMedical Pharmacy Implementation Prior Authorization Program (BCBSKS)

Policy CodePolicy N/A

Change TypeVendor transition; PA workflow change

Effective DateAug 15, 2025

Next Review Date

On This Page

Date of service is on or after 2025-08-15. Providers may begin contacting Prime on 2025-08-07 for treatments with dates of service on/after 2025-08-15.

Routine requests: GatewayPA.com (portal for routine requests)
Urgent/retroactive/expedited requests: call Prime Operations at 800-424-1713 (Prime has staff available 24/7 for urgent requests)
This replaces prior CoverMyMeds/fax workflows for medical-benefit drug reviews

Documentation Required

Required information for PA requests

PA requests must include provider, member, medication, and clinical information as detailed below. Include complete ordering and rendering provider details, member demographics, medication administration details (including place of service and HCPCS/drug), dosing and timing, and supporting clinical documentation.

Ordering/rendering provider: name, Tax ID (TIN), practice address, office telephone and fax
Member demographics: member name, date of birth, member ID number, height, weight, diagnosis code
Medication details: place of service code, requested drug name or HCPCS code, dosage, frequency, anticipated start date of treatment
Clinical documentation examples: clinical notes, pathology reports, relevant test results

Billing Rule

Transition of care and authorization continuity

Authorizations issued by BCBSKS for dates of service before August 15, 2025 remain effective until their stated end date. To continue treatment after an authorization expires, providers must obtain a new authorization from Prime prior to the authorization end date. Claims for dates of service after the authorized end date will be denied if a successive authorization from Prime has not been obtained.

Operational note: claims for dates after the authorized end date will be denied if successive authorization from Prime is not obtained prior to expiration

Documentation Required

Prime review escalation process

If additional detail is needed during review, the case will be routed to a Prime pharmacist for provider outreach. Cases may be escalated to a Prime physician who will discuss the case with the ordering provider.

Escalation path: Prime pharmacist outreach, then Prime physician escalation if needed